Covid 10 – Emergency Dental Treatment Form

I understand the novel coronavirus causes the disease known as COVID-19. I understand the novel coronavirus virus has a long incubation period during which carriers of the virus may not show*

I have been made aware of the Alberta Dental Association and College guidelines that under the current pandemic all non-urgent dental care is not allowed. Dental visits should be limited to the treatment of ongoing tissue bleeding, alleviate severe pain or infection or conditions that significantly inhibit normal operation of teeth and mouth, and issues that may cause anything listed above within the next 3 to 6 months.*

I confirm I am seeking treatment for a condition that meets these criteria.*

I confirm that I am not presenting any of the following symptoms of COVOID-19 identified by Alberta Health Services:

Fever > 38C

Initial

Cough

Initial

Sore Throat

Initial

Shortness of Breath

Initial

Shortness of Breath

Initial

I confirm that I am not currently positive for the novel coronavirus*

I verify that I have not returned to Alberta from any country outside of Canada whether by car, air, bus or train in the past 14 days.*

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Alberta Health Services require self-isolation for 14 days from the date a person has returned to Canada.*

I understand that Alberta Health Services has asked individuals to maintain social distancing of at least 2 metres (6 feet) and it is not possible to maintain this distance and receive dental treatment.*

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Alberta Health, the Communicable Disease Control or any other governmental health agency.*

LIST OF DENTAL TREATMENT*

Select the plus sign on the right to add more.

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have the above listed emergency dental treatment completed during the COVID-19 pandemic